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and a half inches from its neighbour. The wounds were twoand a half inches deep. As the trident was in a highlyseptic condition when it was thrust into the man’sshoulder, and as it had been embedded there for over

two days, it is not surprising that all the woundswere suppurating and that the arm and shoulderwere much swollen and reddened. After some days’treatment the cellulitis seemed to improve but 11 daysafter admission haemorrhage commenced and could not becontrolled by plugging. On the night of August 30th thewound from which most blood was exuding was thereforeenlarged and an attempt was made to tie the axillary arteryin its third part. This was found to be impossible owing tothe fact that a large portion of the artery was in a sloughingcondition. The left subclavian artery was then tied in itsthird part, the operation being rendered somewhat difficultas the assistant had to maintain direct pressure on thebleeding point and so the shoulder could not be depressed.Three days after the operation a herpetiform eruptionappeared on the left loin and on the right shoulder andupper arm accompanied by considerable fever and an ictericappearance of the skin and conjunctiva. The fluid from thevesicles was examined and found to be sterile. The manleft the hospital practically well and was seen again byDr. Highet two months later when the following note wasmade : "Seen at the Criminal Court to-day. Is well and

strong ; all wounds cicatrised ; humeral and radial pulseimperceptible ; movements of shoulder-joint very good ; armrather thinner than right arm but not markedly so."

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Annual Meeting.THE annual meeting of this society was held on March lst,

Sir R. DOUGLAS PowELL, the President, being in the chair.-The annual report showed that the financial condition of thesociety was extremely satisfactory but that the attendance atthe meetings of the society left something to be desired. Witha view to improve this it had been decided by the council toprint abstracts of papers in advance and to send them withformal invitations to persons named by the authors. Duringeach session at least one special discussion would be

arranged. The President’s address in connexion with thecentenary of the society would be delivered on May 22ndand the Marshall Hall prizeman, Dr. Henry Head, F.R.S.,would give an address on Afferent Nerves under a NewAspect on May 23rd. A banquet would be held on May 22ndat the Hotel Cecil, at which the society would entertain HisRoyal Highness the Prince of Wales and other distinguishedguests. A conversazione would be held on the night of

May 24th and during the week there would be an exhibitionillustrating medical matters of 100 years ngo.The HONORARY LIBRARIANS announced that a card cata-

logue of the books in the library had been completed.The PRESIDENT gave the Annual Address, in the course of

which obituary reference was made to those Fellows of thesociety who had died during the last year. In discussing thework of the society the question of a possible amalgamationof the various metropolitan medical societies was raised andthe advantages accruing from such a scheme in the way ofeconomising time and money were clearly emphasised.-Dr. J. E. POLLOCK proposed, and Sir WILLIAM H. BROADBENTseconded, a vote of thanks to the President for his addressand supported the idea of initiating an amalgamation of thesocieties.-Sir THOMAS SMITH proposed that the council ofthe society should be requested, with as little delay as pos-sible, to im ite the leading medical societies of London toarrange for a joint meeting for the purpose of consideringthe advisability of amalgamating and to take the necessarypreliminarv steps for that purpose.-The motion was secondedby Mr. D. H. GOODSALL and unanimously carried.

Sir W. H. Broadbent and Dr. T. Buzzard were elected newvice-presidents of the society. Dr. Howard H. Tooth, Dr.Dawson Williams, Mr. Clinton T. Dent, Mr. A. MarmadukeSheild, and Mr. Thomas Wakley, jun., were elected newmembers of the council.

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Discussion on the Subseqoent Course and Later History ofCases operated on for Appendicitis.

An adjourned meeting of the society was held or

March 7th, Sir R. DOUGLAS POWELL, the President, beingin the chair.The PRESIDENT resumed the discussion on the Subsequent

Course and Later History of Cases operated on for Appen-dicitis. He said that he had nothing to add to the subjectof absence of relief after operation in cases of appendicitis.He had met with pulmonary embolism many times in thesequel of injuries and of surgical operations and, with-out giving actual numbers, he felt sure that it hadbeen more frequent in his experience after operationsfor appendicitis than after other operations. Althoughthis complication did not appear from the statistics to bevery common it was probable that many of the cases

of pleural effusion and dry pleurisy occurring after operationwere due really to pulmonary infarction. In Oppenheimer’sseries 16 per cent. of the acute cases developed pulmonaryembolism. With a view to prevent this complication it wasadvisable in the chronic cases to keep the patient in bed fora few days before operation, to order a simple diet, and togive small doses of calomel as an intestinal antiseptic. An

interesting case of secondary pulmonary infarction whichhad become tuberculous occurring some months after an

operation for appendicitis had been observed in consultationwith Mr. Charles Hartley and the patient was now progressingsatisfactorily abroad.Dr. H. P. HAWKINS drew attention to the fact that in spite of

increased earliness of operation the mortality from appendi-citis showed no fall and in some cases a slight rise as com.pared with a period of ten years ago. He accounted for thisby a gradual rise in the severity of the disease which wasoccurring pari passu with its increased frequency. Heagreed that a great reduction in the mortality was to beanticipated by continual insistence on early operation. Asregards imperfect relief or recurrence of symptoms afterexcision he thought cases were few. Putting on one sidecases where confusion occurred between appendicitis,floating kidney, and renal and biliary colic (the occasionaldifficulty of differential diagnosis being allowed), he believedthat the rest of the cases of imperfect relief should beattributed to a colon neurosis. Of this group mucous colitis,a non-inflammatory motor and secretory neurosis, was thebest known example, but it shaded off into minor grades ofpure enterospasm of which a clinical description could begiven. In all degrees of the neurosis, if the trouble occurredin the ascending colon with attendant neurasthenia andsecondary hypochondriasis the appendix could be excisedwithout necessarily giving relief.

Sir WILLIAM H. BENNETT believed that the real value ofstatistics lay in their relative rather than their absoluteapplication and that those derived from hospital practicepresented a gloomier picture than the truth. In cases of

appendicular abscess it was not desirable to attempt toremove the appendix for the sake of making sure that theorigin of the disease was destroyed. He had never regretted leaving the appendix in such cases but he had on more than

one occasion regretted making the attempt to remove it.

Complications often arose from inadequate operations in

simple cases of appendicitis and the practice of leavinga stump was, in his opinion, often a source of after

! trouble. The fact that a stone in the right ureter might: give rise to symptoms suggesting appendicitis was illus-trated by a case in which a healthy appendix was foundibut in which a ureteral calculus was discovered atIthe operation and passed four days later per urethram. It was advisable to submit doubtful cases to examination by- the x rays for the purpose of excluding this source of error.- No prolonged pain in the scar was ever met with if a ruleswas made never to apply a ligature through the undivided; peritoneum. Recurrence of symptoms had been present inE three cases, in all of which a history of malaria, and in two- of which a history of dysentery, had been noted. Foacal) fistulæ occurred in 5 per cent. of cases but many of these healed very quickly and would be better regarded as

ytemporary fascal discharges rather than true fistulas.1 Mr. C. B. LOCKWOOD stated that the main object of the dis-

cussion was to learn what happened to those patients who, had had the appendix removed. It was clear that the. method of proceeding by clinical statistics alone was in-

e complete and fallacious, mainly because so many possibilitiesv were ignored and so much was omitted. The future of

the patient must in a large measure depend upon the diseasewhich existed in the appendix at the time of its removal.

f For instance, some were tuberculous, some were cancerous,and some were actinomycotic. Correct conclusions could not

n be arrived at by examining the appendix with the naked eye-

643

and in a scientific inquiry clinical evidence should be sup- J

ported by microscopical and, if possible, by bacteriological 1examination. Some of these requirements had been fulfilled iin the synopsis of 200 cases of his own which he had pro- vided. In a case of primary columnar-celled carcinoma of the appendix the disease was unrecognisable by the naked ieye and although the csecum and the end of the ileum were removed the disease continued to grow slowly in the pelvic glands and ultimately proved fatal. A sectionof the ordinary type of carcinoma of the appendix had !been given to him by Mr. W. McAdam Hccles who saidthat on removal the nodule was thought to be tuber- culous. If appendices were systematically examined

probably 1 in 250 would prove to’ be cancerous. Only fourinstances of tuberculous disease of the appendix occurred inthe 200 cases but the prognosis of this condition wasunfavourable. The question of removing the appendix afteran appendicular abscess had been evacuated should bedecided in each case on its merits, but as a general rule thatcourse should be adopted if the general’ and local conditionsdid not forbid it. The commonest disease of the appendixwas ulceration of the mucosa with penetration of bacteria intothe tissues of the mucosa and into the lymphatics andonwards through the hiatus muscularis into the peritoneum.The ulceration was associated with septic, muco-purulent, orfsscal contents and the latter with concretion in 23 out of200 cases. Reference was made to two cases of mesentericthrombosis in patients suffering from acute intestinalobstruction. Among the causes of recurrences of appen-dicular symptoms was the presence of enormous dilatationof the caecum with fæces which could be readily treated bymeans of enemata and care in diet.Mr. W. H. BATTLE referred to five cases in which there

was a return of symptoms after an abscess had beenevacuated with success. In all of these the appendiceswere removed later and showed marked pathologicalchanges. In five other cases a secondary abscess formed,the appendix not having been removed at the first opera’-tion. Sinus formation occurred in six cases after a

localised abscess had been opened and drained. Intwo other cases operation was performed for commencingperitonitis where there had been previous localised suppura-tion. The appendix had been removed in seven cases

after an abscess had been evacuated and all inflam-

matory symptoms had subsided. In several of these casesconcretions were found and in all these were evidencesof pathological conditions which might give rise to furthertrouble. Similar conditions were found in the appendicesremoved after evacuation of the abscess into the lower part ofthe bowel. The appendix had been successfully extirpatedin seven cases where localised suppuration was present but inone of these cases the patient had died from a cardiacseizure four days after the operation. The condition of the

appendix was also described in several cases which had diedfrom general peritonitis or from some other cause which wasuot fully explained by the post-mortem examination. In

conclusion, early evacuation of an abscess and secondaryremoval of the appendix were advocated in the majority ofcases and the removal of a concretion at the firt opera-tion was not considered an indication for believing thatthe patient would be free from recurrence of symptoms.Mr. GEORGE R. TURNER preferred to operate on all acute

cases as early as possible unless they were obviouslyrecovering. In such cases the mortality was 10 in 125 andthe majority of the fatal results were obtained in patientswho were seen late in the attack. Operation during thequiescent stage produced a mortality of 0 ’ 5 per cent. in thecombined statistics of five hospitals ; in all other cases thecombined statistics showed a death-rate of 23 per cent. A

great reduction of fatal results would be produced byoperating at an early period in the disease and at the sametime complications and unfavourable sequelae would also bemuch reduced in numbers. The method of opening theabdomen by separation of muscular fibres was justifiable insimple cases but was inadequate when pelvic complicationshad to be dealt with.Mr. H. F. WATERHOUSE referred to the fact that although

appendicitis was three times more common in the male thanin the female sex complications were infinitely more frequentin women. The appendix should be removed flush with theexcum and the absence of this precaution was responsiblefor recurrent trouble in some cases. Ventral hernia did notoccur when the muscle fibres were separated and not incised—a method which gave room enough in all cases. The debatehad emphasised the necessity for carefully examining the

right ovary and tube at the time of operation. Pyonephrotickidneys and ureteral calculi were possible sources of errorsin diagnosis. Early operation was a very important factor inreducing the mortality of the disease and in 19 cases whichhad been operated on within 24 hours of the onset of sym-ptoms there had been no deaths in spite of the fact thatperforation had been present in three instances. The appen-dix should not be removed when evacuating an abscess.

Mr. J. P. LOCKHART MUMMERY emphasised the import-ance of care in the after-treatment of operation cases.The discussion was then adjourned until the next ordinary

meeting of the society.

OBSTETRICAL SOCIETY OF LONDON.

Chyluria complicating Pregnancy.-Pregnancy in a Rudi-

mentary Uterine Cornu. Grape-like" b"arconaa of theCervix Uteri.A MEETING of this society was held on March lst, Dr.

W. R. DAKIN, the President, being in the chair.Captain J. C. HOLDICH LEICESTER, I.M.S., read a short

communication on a case of Chyluria in a Eurasian, 18 yearsof age. She had been married eight months and had advancedto the eighth month in pregnancy. She presented herselffor treatment at the Eden Hospital for Women, Calcutta, onaccount of severe pain on micturition. The urine hadbecome milky for the first time on the previous day. Forfive months she had had a swelling in the right thigh whichhad occasionally given rise to pain. The swelling felt likean enlarged gland in the femoral rirg; it quickly subsided.On examining the urine drawn by catheter it was milky-white in colour with a faint pink tint and containedsome white sediment ; it had a specific gravity of 1022and was faintly acid ; the albumin amounted to one-

quarter. Traces of blood and chyle were present. Phos-

phates were in excess. On microscopical examination,besides phosphates and oxalates and blood corpuscles,bladder epithelium and several filaria embryos were found.The urine was found to clot shortly after being passedbut soon broke down again and remained fluid. Both thelabour and the puerperium passed naturally except fora rise of temperature to 101.8° F. on the sixth day afterdelivery. The urine as a rule continued to preserve itsmilkiness. The blood was examined on three separateoccasions and on each was found to be swarming with filariaembryos. The case resisted all treatment, whether of diet,drugs, or posture, and the condition of the urine remainedpractically the same throughout. The patient’s generalcondition showed considerable improvement during the timeshe was in hospital. In Captain Leicester’s opinion therewas little doubt that in this case the pregnancy was theexciting cause of the chyluria, which was due to the dis-turbance of the pelvic lymphatics which had been previouslyaffected by filarial obstruction of the thoracic duct.

Dr. A. H. N. LEWERS related a case of Pregnancy in aRudimentary Uterine Cornu in which he had operated forsevere internal haemorrhage. The patient was 24 years ofage and had been married 13 months. She had had a mis-

carriage at about the sixth month of pregnancy six monthsafter marriage. One menstrual period had occurred 13weeks after the miscarriage. On the day prior to heradmission to the London Hospital she was suddenly takenill with severe pain in the abdomen. Preparations were atonce made for operation. The patient’s condition was sobad that both rectal and intravenous saline injections andhypodermic injections of strychnine were resorted to. On

opening the abdomen the ovum was discovered on the leftside. The sac burst on handling and a foetus of at leastthree months gestation escaped with the liquor amnii. The

pedicle was found to be much thicker than in a tubal

gestation ; it was transfixed and tied a second time torender it secure. On subsequent examination the wall ofthe sac proved to consist of muscular tissue, about half aninch in thickness, formed by the rudimentary horn on theleft side. It was noted that the left ovary did not cont iinthe corpus luteum, from which Dr. Lewers inferred thatexternal migration of the ovum from the opposite ovaryhad occurred. The patient passed a decidual cast eightdays after the operation and made a good recovery.

Dr. HERBERT WILLIAMSON showed a specimen of"Grape-like" " Sarcoma of the Cervix. He remarked uponthe rarity of this form of sarcoma of the cervix, only16 cases having been previously recorded. The specimen